Master's Degree
programme
in International and
Cross-cultural Relations
Second Cycle (D.M. 270/2004
)
Final Thesis
Obstetric Violence
as Violence Against Women
A Focus on South America
Supervisor
Ch. Prof. Sara De Vido Assistant supervisor
Ch. Prof. Luis Fernando Beneduzi
Graduand Laura Zazzaron 836492
Academic Year 2016 / 2017
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Obstetric Violence as Violence Against Women:
A Focus on South America
Contents
INTRODUCTION ... 4
Chapter 1. Obstetric violence and reproductive rights ... 7
1. What is obstetric violence? ... 7
1.1 History of Women dealing with obstetric care before the 50s ... 9
1.2 Obstetric violence since the 50s up to today ... 10
1.3 Different types of obstetric violence ... 11
2. Why is obstetric violence so dangerous? A medical perspective ... 14
2.1 Physical practices ... 14
2.2 Mental impact of obstetric violence ... 18
2.3 Women in subordination in the medical field ... 19
2.4 Today’s characteristics ... 20
3. Reproductive rights. An historic overview ... 21
3.1 Reproductive Rights (not) in the MDGs but in the SDGs Agenda ... 25
4. Historical and Social Context of Obstetric Violence in South America ... 27
Chapter 2 Legal framework of obstetric violence: are there any rules? ... 32
1. International legal framework ... 33
2. At Regional Level ... 36
3.At national level ... 38
3.1 Venezuela ... 39
3.2 Mexico ... 40
3.3 Argentina ... 42
3.4 A new trend in recognising obstetric violence? ... 43
CHAPTER 3. Obstetric violence as a violation of human rights ... 45
1. Which human rights are violated with obstetric violence? ... 45
The Right to Life, Liberty, and Security ... 46
The Right to Health ... 46
The Right to Privacy ... 49
The right to information ... 50
The Right to Equality and to be Free from Discrimination ... 53
Discrimination against women ... 54
Discrimination as a woman from rural areas and as indigenous people ... 55
The Right to Not be Subjected to Torture or Other Cruel, Inhuman, or Degrading Treatment or Punishment ... 56
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The Right to Enjoy Scientific Progress and its application ... 57
5. The right to maternal care. An overview ... 58
2.1 What does maternal care include? ... 59
2.2 When is it important? ... 60
3. Is it possible to talk about institutional violence? ... 65
3.1 Current status of the rights ... 69
3.2 Discrimination within dedication ... 69
4.Issues of intersectionality ... 72
4.1 Intersectionality in the access to health services ... 73
4.2 Situation in Latin America ... 74
6. Is there any international framework? ... 80
CHAPTER 4. Obstetric violence in the wards ... 89
1. Obstetric violence in concrete ... 89
1.1 Venezuela. Ten years later ... 90
1.2 México and its Tribunal Simbólico ... 91
1.3 Situation in Argentina ... 93
1.4 In Brazil ... 94
2. The Inter-American Court and Commission of Human Rights ... 95
3. Similar cases at international level ... 106
4. Barriers to access to justice ... 109
5. The “Maternal Mortality” Factor ... 111
5.1 Who are the victims? ... 113
Chapter 5. What’s next? ... 115
1. Projects of Law ... 115
2. What's next? ... 117
CONCLUSION ... 120
BIBLIOGRAPHY ... 124
Acts and Documents ... 124
International Conventions and Declarations ... 132
Regional Conventions and Declarations ... 133
Other Regional Documents ... 134
Acts and Documents of the United Nations and its committees ... 135
Special Rapporteurs ... 137
Documents of the World Health Organisation ... 137
National Laws ... 139
Project of Laws ... 141
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Cases judged by the Inter-American System of Human Rights ... 142
Other cases... 143
National Judgments ... 143
Other sources ... 143
4 INTRODUCTION
Obstetric violence is considered as a particular type of mistreatment towards pregnant women during their pregnancy, labour time and postpartum care by doctors, nurses and health personnel in general. It can hurt physically, mentally and psychologically and can occurs in both public hospital and private health facilities. It takes different forms such as physical violence or verbal abuse.
Even though it has been performed for decades in many maternity wards all around the world, it has been recognised under the name of obstetric violence only in the last decade, most precisely since 2007 when the first national law recognised it.
The focus of the study is on Latin America because, up to today, it is the only region of the world where countries have typified it in their national law. Some of them (Venezuela in 2007, Argentina in 2009 and some states of Mexico since 2008) have also recognised it as a crime therefore it is possible to find it in their penal code and be persecuted for it.
This study will especially try to understand whether obstetric violence can be considered as a type of violence against women. It also investigates whether obstetric violence can be considered as institutional violence, and a violation of women’s human rights. In this case, which human rights are violated and in which binding and non-binding instruments these rights are recognised.
Finally, the study will identify the most relevant precedents of international judgments which show a breach in international and regional documents to understand if obstetric violence can be judged as violence. These are the most important questions this study will try to answer. To do so, different characteristics are taken into consideration and analysed in five different chapters.
The first chapter gives a definition of obstetric violence, identifying the main actors involved in the violence and gives an overview of the history of women both in the field of medicine and as patients under the raise of patriarchy and of the history of obstetric violence since the 50s up to today’s characteristics. Subsequently, there is a presentation of the various forms that obstetric violence can take, divided in physical and psychological mistreatments. Obstetric violence will be also studied from a medical point of view and the main physical procedures which are often use in the maternity wards all around the world are criticised according to their dangerousness. A brief section on the mental impact obstetric violence can have on women who are victims will follow.
Obstetric violence will be later studied from the point of view of human rights to see if it can be considered as a violation of reproductive rights. For this reason, a section is dedicated to the most important stages in the history of the recognition of reproductive rights. A special focus will be given to the MDGs and SDGs Agendas and the role reproductive rights have on them.
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Lastly, to conclude the overview of obstetric violence, a section is dedicated to the social and political contexts in which the laws which typified this type of violence have been adopted.
The second chapter relies on the legal framework of obstetric violence. At international level there is no recognition of this type of violence therefore no international legal documents include it. Nevertheless, there is a supporting body of articles in conventions and declarations which rule the field of health. This chapter is divided into three levels. The first one is dedicated to the international legal framework, the second one to the regional (Latin America) instruments and finally, the third section to the national laws which includes obstetric violence. Until now, only six countries have typified it in their laws and only three of them have recognised it as a crime. The last section of the chapter listed the new countries that in the last few years have added obstetric violence in their law against violence against women.
The third chapter will list the human rights that can be violated through obstetric violence. For each human right, it is given the main international and regional instruments where it is possible to find the articles which regulate it. A brief section will give an overview of the right to maternal care and what it includes. Lately, the focus shifted to the main characteristics of institutional violence, what includes and the principles which regulate the action of health personnel. Lastly, the concept of intersectionality is introduced. This concept applies to many cases of obstetric violence as well as in many cases of violence against women, where victims are discriminated on the basis of two or more discriminative basis. As clear alongside the whole study, the major victims of obstetric violence are Indigenous women, women from the poorest sectors of the population and/or women from rural areas.
In chapter four, obstetric violence is analysed in concrete. There will be given some data and statistics on the actual situation of the countries involved in the study and cases of the violence in the three countries who criminalised its practices. As obstetric violence is not recognised at international level, there cannot be international judgments, nevertheless, many judgments by the Inter-American Court of Human Rights dealt with similar cases. A quick view of the reasons why women victims of such violence do not report it, will follow. To conclude the chapter, there is an explanation of maternal mortality, its causes and consequences and the reason of its importance in the issue.
The last chapter of the study is dedicated to the new projects of law throughout Latin America, many of them will probably be approved in the next months. And finally, the last section is dedicated to some of the most important national plans and actions which have been taken in the last years to
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improve their health services and to tackle this type of violence, by the countries which recognised obstetric violence in their law.
It is right to point out that not all health facilities are carrying out the procedures described in the course of the study in a routine way. Most of the cases are procedures used in case of emergency by professional doctors and obstetricians who do care about the health of the mother and the baby. Despite this, numerous statistics show that in many areas of the world there is an excessive medicalization at the time of delivery with consequences that may have disastrous outcomes as described throughout the chapters. An inverting trend with respect to this is taking place precisely in Latin American where some laws have identified and criminalised this type of violence. Latin America is witnessing also the birth and growth of several organizations for the spread of knowledge and information regarding the problem. Moreover, all over the globe, and not only in Latin America, there are projects of law in the parliaments seeking the promotion of a more humanised birth, according to the times and the physiological needs of each woman and child.
7 Chapter 1. Obstetric violence and reproductive rights
Contents: 1. What is obstetric violence?; 1.1 History of Women dealing with obstetric care before the 50s; 1.2 Obstetric violence since the 50s up to today; 1.2 Different types of obstetric violence; 2. Why is obstetric violence so dangerous? A medical perspective; 2.1 Physical practices; 2.2 Mental impact of obstetric violence; 3. Women in subordinate position led to obstetric violence or the reverse?; 3.1 A social and historic overview of women in subordination in the medicine field; 3.2Today’s characteristics; 4. Reproductive rights; An historic overview; 4.1 Reproductive Rights (not) in the MDGs but in the SDGs Agenda; 5. Historical and social context
This first chapter aims to give a definition and clarify the concept of obstetric violence, the acts and procedures which can be part of it and the differs types it can be divided in. From one hand, the dangers of obstetric violence will be analysed under a medical perspective, focusing on the main physical procedures which, in specific contexts of over medicalisation, can be considered as obstetric violence and the psychological impact they can have on women. On the other hand, the section will focus on obstetric violence linked to the position of women in the health care. Being obstetric violence a cause of the violation of reproductive rights, it is necessary to include them in the study. Thus, in the following section, there will be a brief overview of the history of reproductive rights with a focus on their inclusion in the MDGs Agenda. Lastly, the historic context which led to the adoption of the laws in which obstetric violence is included will be analysed.
1. What is obstetric violence?
“Come on, you need to open your legs, obviously you didn't mind that nine months ago” “You screamed of pleasure when you did, now it's time for you to scream of pain” “If you liked the sweetness now stand the bitterness” 1
So hard to believe that these sentences could have been said in different languages all around the world, in a lot of delivery rooms, often screamed to women during what is supposed to be one of the most joyful and fulfilling time in a woman's life.
Harsh sentences like these, together with coercive practices and other inhumane treatments are all practices recollected under the umbrella of obstetric violence.
This kind of violence, which would be extremely disrespectful on a normal day, is even more dangerous due to the peculiar physically, socially, and psychologically period, pregnant women are living.
1 Bellón Sanchéz Silvia. (2014). Obstetric Violence. Medicalization, authority and sexism within Spanish obstetric
8
As reported by the WHO in 2015, a large number of women around the world experience disrespectful and abusive treatment during childbirth in facilities.2 This treatment has assumed different labelling over the years until the last decade when there is a more international trend towards the use of the lemma of “obstetric violence”.
The first definition of obstetric violence came from a law entered into force in March 2007 in Venezuela. The Organic Law on the Right of Women to a Life Free of Violence at its article 15(13), defines obstetric violence as:
“[...] the appropriation of a woman's body and reproductive processes by health personnel, in the form of dehumanizing treatment, abusive medicalization and pathologization of natural processes, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.” 3
Obstetric violence consists then in any act, behaviour or omission, by health personnel which directly or indirectly affects the body and the reproductive processes of women. It can occur in both public and private health care facilities during obstetric care and can either physically or psychologically harm a woman at any time during her pregnancy, birth and postpartum period. Obstetric violence can be performed in a number of different way: through a lack of access to reproductive health facilities, through an overuse of medical intervention during the processes and through a cruel, inhumane or degrading treatment. This general disrespect toward the labouring woman, results in an undermining of her right and ability to make autonomous decision about her reproductive processes.
All pregnant women can be victims of obstetric violence. Pregnancy is the term used to describe the period in which a foetus develops inside a woman's uterus and it usually lasts 40 weeks. Nevertheless, a woman is still at risk of pregnancy-related problems within 42 days of termination of pregnancy. Postpartum health problems can include infections, excessive bleeding, poor bladder control in case of a vaginal birth, among others. This means that obstetric care can be required also immediately after the delivery up to about 6 weeks after it. In fact, women should be closely monitored during the immediate postpartum period, reassessing her clinical status and documenting their conditions.4 Taking care of pregnant women there are gynaecologists and obstetricians. But not only. All health personnel, from first aid assistants to medical students and in many cases nurses, can commit obstetric
2 WHO. (2015). The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva,
Switzerland. Retrieved from http://apps.who.int/iris/bitstream/10665/134588/1/WHO_RHR_14.23_eng.pdf?ua=1&ua=1 p. 1
3 Gaceta Oficial No. 40.548 de la República Bolivariana de Venezuela, Ley Orgánica Sobre el Derecho de Las Mujeres a
una Vida Libre de Violencia. Caracas, Venezuela, April 23, 2007. Available at http://www.derechos.org.ve/pw/wp-content/uploads/11.-Ley-Org%C3%A1nica-sobre-el-Derecho-de-las-Mujeres-a-una-Vida-Libre-de-Violencia.pdf
4 CONAMED. (2012). Recomendaciones Generales para Mejorar la Calidad de la Atención Obstétrica. México, p. 7.
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violence and have their part in performing it either materially or with their silence. When they take active part, they can refuse to administer pain relief or other medications as well as water or food to the woman. A typical form of abuse they perform is the verbal one, judging outcomes or trivialising the procedures.
When talking about obstetric violence, it is necessary to keep in mind that not in all health facilities there are cases of obstetric violence. Nevertheless, in many of them, there is a negative custom to mistreat pregnant women for different reasons. Studies on why obstetric violence exist5, approached the problem of obstetric violence as a problem of the quality of attention in health facilities. The problems sort out because of the difficult work conditions of health personnel. That includes, among other reasons, the great number of people that arrive to the facilities and have to be attended, long shift hours and low resources available in the facilities (i.e. syringes, tools, minimum of essential medicines as prescribed by the WHO in the WHO model list of essential medicines).
1.1 History of Women dealing with obstetric care before the 50s
Until the Middle Age, women used to take care of other women when the latter were pregnant. No person was better to take care of such a delicate period in a woman’s life than another woman who perhaps had already passed the joy of a pregnancy and the pain of a delivery.
But it is during the Middle Ages that men, who had already the control of the field of medicine, started taking more and more authority in assisting childbirth.
In fact, during those years, men have exclusive access to education and the field of gynaecology and obstetrician begins to be studied and practiced by males.
At first, midwives were used as intermediaries between physicians and the patients to overcome the problem of a man taking care of women’s sexuality. In doing so, midwives started then to be relegated to a position of subordination until the point that performing their job was really difficult due to new regulations on the field. Despite the great effort of midwives to safeguard their work, they eventually had to witness the slow decline of their presence in the field of gynaecology and obstetrics to make room for a greater presence of men in their place and assist at their job becoming part of the male scientific practice.6
5 See for example Castro R., Joaquina Erviti. Disrespectful and abusive treatment, 2015 and Sadler M., Moving beyond
disrespect and abuse: addressing the structural dimensions of obstetric violence. 2003
6 Bellón Sanchéz Silvia. (2014). Obstetric Violence. Medicalization, authority and sexism within Spanish obstetric
10 1.2 Obstetric violence since the 50s up to today
Even when still there was no unanimous word for such aberrant procedure, obstetric violence was performed at all levels. The first clue of what would have been later known as obstetric violence dates back in 1958. An article entitled "Cruelty in Maternity Wards” was published by the Ladies' Home Journal, an American magazine considered among the most important women’s magazines of the 20th century in the United States. The article told tales about the inhumane treatments women received during their labour in public health facilities.
The article had an enormous impact on public opinion and even succeeded in putting forward the rights of pregnant women begging the movement that allow husband to be present during the labour time of their wives into maternity wards to help their life companions and share the experience of first moments of life of their baby. The investigative report began from a letter sent to the journal by an anonymous “registered nurse’’ who denounced the mistreatments in her health facilities and asked, or better, begged the journal to “investigate the tortures that go on in modern delivery rooms”. After the letter, the journal received hundreds and hundreds of letters from readers denouncing their mistreatment at the time they were giving births in the delivering rooms all around the country. The journal received even letters containing confessions from nurses who, fearing to lose their job if they were to speak up, allowed with their tacit consensus to the mistreatments. To confirm the confessions, another anonymous letter from an obstetrician described the cruel treatments women had to undergo during delivery.7
50 years later and in certain cases, things seem not to have changed so much.
After the revelations of the mistreatments, however, we would have noticed no immediate significant improvement in pregnancy, childbirth, and postpartum healthcare. We must wait until the mid-60s when feminist movements arouse gained more and more power and voice. Rights of pregnant women started finally have the attention they deserve.
From the 50s onwards, childbirth has started to be seen as a dangerous event in woman’s life and the safest place to give birth switched from being the pregnant woman's home to the hospital. As time went on, also the mere help of professionals became more and more essential interventionism until the point that pregnancy started to be considered from a pathological point of view and so, as a pathology to take care of and cure. From this perspective, even normal pregnancies with no complications and then no subject to any medical interventions, are treated like sequelae in need of a
7 Goer, H. (2010). Cruelty in Maternity Wards: Fifty Years Later. The Journal of Perinatal Education, vol. 19(3), pp. 33–
11
medical intervention. And the moment of the deliver, a moment so natural during a woman’s life began to be perceived as dangerous if performed alone and in need of a specialist.8
In this regard, professor and pioneer of obstetric violence as a violation of sexual and reproductive rights Marbella Camacaro Cuevas, forged the sentence “patologizando lo natural, naturalizando lo patológico” (pathologizing the natural, naturalising the pathologic) to better resume the issue. That is, the idea that delivery is seen as an illness to be treated, eventually considering natural to perform a C-sections or episiotomy when it is not. As Camacaro argues, women are nowadays subjected to procedures that have negative consequences for their health. This is not only because of the treatments itself but for the mere fact that women are treated as sick when they are not. Medical interventions then become the normality and, in doing so, women lose their ability to do it by themselves.9
Therefore nowadays, many women consider normal when doctors hurry their deliveries performing C-sections with no medical necessity. But high rates of C-sections and episiotomy are exactly the contrary of what medical recommendations and the WHO’s guidelines suggest.
1.3 Different types of obstetric violence
There are there are many practices which can be catalogued as obstetric violence and they can take place during the pre-partum care, delivery, postpartum care and including during the first stages of childbearing. Especially, in the following 6 weeks after the birth.
Obstetric violence can be manifested through verbal humiliations, discrimination or humiliation based on race, ethnic or economic background, age, HIV status, among others.
As reported by a document by GIRE 10 the manifestations of obstetric violence can include: “[…] scolding, taunts, irony, insults, threats, humiliation, manipulation of information and denial of treatment, not providing referrals to other services in order to receive timely assistance, delaying urgent medical care, indifference to women’s requests or complaints, failure to inform or ask women about decisions made during the various stages of labour, use of women for didactic purposes without any respect for their dignity, pain management during childbirth used as punishment, and coercion to obtain “consent”, and finally, even acts of deliberate harm to a woman’s health, among even more serious and obvious violations of their human rights.”11
8 Machado M. (2014). ¿Cómo parimos? De la violencia obstétrica al parto humanizado. (Thesis at Universidad de la
República, Uruguay), section 2 Retrieved from
http://sifp1.psico.edu.uy/sites/default/files/Trabajos%20finales/%20Archivos/trabajo_final_grado_machado.pdf
9 Marbella Camacaro Cuevas. (2009). Patologizando lo Natural, Naturalizando lo Patológico. Improntas de la Praxis
Obstétrica. Revista Venezolana De Estudios De La Mujer, vol. 14(32). Caracas, Venezuela, pp. 154-161
10 GIRE, Fundación Angélica Fuente. (November 2015). Obstetric Violence. A Human Rights Approach., p. 13. Retrieved
from ire.org.mx/en/wp-content/uploads/sites/2/2015/11/ObstetricViolenceReport.pdf
11 Villanueva-Egan L.A. (2010). El maltrato en las salas de parto: reflexiones de un gineco-obstetra. Revista CONAMED,
12
Mistreatments can be divided into physical and psychological:12
Physical mistreatment means any invasive practice performed on the woman, the disregard of a woman’s needs and pain, the denial of treatment or, at the contrary, the abuse of unnecessary medicalisation which includes all procedures which are not essential from the medical point of view or which are not clinically justified to enhance the health of either the woman and the baby.
The most common medical interventions not considered as essential and even classified as dangerous by the WHO are: the use of oxytocin to induce labour, enemas, shaving of pubic hair, the Kristeller manoeuvre, episiotomy, unnecessary C-sections, repeated vaginal exams by different medical staff and/or by different apprentice students, the prohibition to have a family member into the birthing rooms at the time of the delivery, the fact of not providing information and not asking for consent on procedures, the obligation of the supine position during the delivery and the prohibition to freely move during the delivery.
Physical abuse includes also any actions involving the use of force (e.g. physical restraint, the beating, slapping, kicking, pinching of women during delivery, the physical restrain of women to the bed during delivery, the forced medical detention in health facilities for failing to pay, medical interventions without the informed consensus of the mother among other dehumanizing and rude treatments). Medical interventions carried out without informed consent happen when the parturient neglect and/or is not informed before the performance of the procedure. This represents a severe violation of the right to information as well as it undermines the freedom of choice of the woman. On the other side, obstetric violence has a great impact on the psychological sphere, too. It happens when a woman is criticised for crying during labour, screaming because of the pain and also for being afraid and asking for questions and doubts. Dehumanising practices include mocking comments, humiliations, discrimination, judgments, ironic remarks, trivialisation of the explanations, miscarrying attitude, calling by nicknames, in general the addressing of the woman as a child, refusing the administration of pain relief or anaesthesia even when asked, preventing early attachment to the child even if not medically necessary.
In these cases, obstetric violence is performed through the use of harsh and rude language, threats, and blaming for poor outcome by doctors, nurses and general health personnel. Even though this kind of abuse might appear less intense, it is very denigrating due to the mental conditions of stress and nervousness a woman experience during such an important period of her life.
12 GIRE. Niñas y mujeres sin justicia. (2015). Derechos reproductivos en México. Mexico, p. 124. Retrieved from
13
This main division of obstetric violence in physical and psychological has been recollected by many organizations and association which promote a safe and natural birth. As a matter of fact, further studies13 have later broaden the spectrum of mistreatments involved.
For example, a deeper subdivision of the different types of obstetric violence has been developed by Bohren et al in 2015.14 Obstetric violence is synthesized in seven different types of mistreatment. Apart from physical abuse and verbal abuse, Bohren added sexual abuse; stigma and discrimination; failure to meet professional standards of care; poor rapport between women and providers; and health system conditions and constraints. Grouped underneath each of these higher-order categories are several more specific elements. 15
While stigma and discrimination behaviours are connected to the cultural factor, the failure to meet professional standards of care includes, among other mistreatments already listed above, the lack of informed consent and a breach on the confidentiality, the denial of information about the procedures employed during the labour process, the abandonment of the pregnant woman or long delays and skilled attendant absent at time of delivery.16
Finally, with respect to the poor rapport between women and providers, the same study asserts the hypothesis of an ineffective communication, a lack of supportive care and a loss of autonomy which take the shape of attitudes like “poor communication, dismissal of women’s concerns, language and interpretation issues, poor staff attitudes, lack of supportive care from health workers, denial or lack of birth companions, women treated as passive participants during childbirth, denial of food, fluids or mobility, lack of respect for women’s preferred birth positions, denial of safe traditional practices, objectification of women, and detainment in health facilities for different reasons. This last case is common above all in some countries of Africa.17 Health staff usually detain women in facilities until their families are able to pay for the care they received. This conduct violates many rights protected by international law such as the right to be subjected to cruel, inhuman, or degrading treatment, liberty and security, not to be detained for non-payment of debt among others.18
13 Bohren MA., Vogel JP., Hunter EC. et al. (30 June 2015). The Mistreatment of Women during Childbirth in Health
Facilities Globally. A Mixed-Methods Systematic Review. PLoS Med 12(6), p. 7
14 Ibid.
15 Madeira S., Pileggi V., Souza J.P. (2017). Abuse and disrespect in childbirth process and abortion situation in Latin
America and the Caribbean - systematic review protocol, additional file No. 1 table 1 “Types of abuse and disrespect of women in the process of delivery and/or abortion.” Systematic Reviews, 6, 152. http://doi.org/10.1186/s13643-017-0516-5
16 Bohren MA., Vogel JP., Hunter EC. et al. (30 June 2015). The Mistreatment of Women during Childbirth in Health
Facilities Globally. A Mixed-Methods Systematic Review. PLoS Med 12(6), p. 7.
17 Center for Reproductive Rights and Federation of Women Lawyers–Kenya. (2007). Failure to Deliver. Violations of
Women’s Human Rights in Kenyan Health Facilities. Retrieved from https://www.reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_bo_failuretodeliver.pdf
14 2. Why is obstetric violence so dangerous? A medical perspective
Obstetric violence can have a huge impact on both the physical and mental health of a woman. Listed in the section, there are some of the main procedures obstetrics and gynaecologists can perform on a pregnant woman. As explained, not all of them are been proved to actually help the mum and the foetus during labour. On the contrary, they are often the main causes of following health problems. All the procedures listed below can be considered as acts of obstetric violence when they are performed without consensus from the woman or when they are used with no medical justification, for example in order to accelerate a labour and thus neglecting the possibility to have a natural vaginal delivery.
2.1 Physical practices
Many physical practices which are often or usually performed to induce or to accelerate a birth, are considered as dangerous by the WHO.19
Perhaps the most common practice performed during a woman’s labour is the practice of episiotomy. The first episiotomy was performed in 1742, in order to make deliveries easier for women.20 Since then, it use has been increased until being considered as routine practice in many health facilities. The episiotomy is a surgical incision into the perineum (the muscles around the area between the vagina and anus) during the second stage of labour to expand the opening of the vaginal opening, to prevent its laceration and the tearing of the perineum and the surrounding tissues during the delivery of the baby and to make the same delivery easier.21 Indeed, it may have some positive aspects, for example, it releases pressure on the foetal head during birth.22 However, the reasons why an episiotomy should be performed are strictly medical. Among other reasons, it can be required in case of maternal or foetal distress and there is not enough time to allow the perineum to completely stretch to allow the child to safely exit; when the mother is tired and not able to push enough anymore; when the baby is premature or in the wrong position or when it is diagnosed with foetal macrosomia (the baby is larger than the average).23 In the last case, delivering without intervention could cause
19 Episiotomy. The cruellest cut? (1 December 2017). Retrieved 15 January 2018, from
https://www.pressreader.com/south-africa/your-pregnancy/20171201/283085594402236
20 Lappen J. R., Gossett D. R. (2010). Changes in Episiotomy Practice. Evidence-based Medicine in Action. Expert Rev
of Obstet Gynecol., vol.5(3), pp. 301-309.
21 Collins. (2018). [online] at: https://www.collinsdictionary.com/dictionary/english/episiotomy [Accessed 15 Jan. 2018]. 22 Pillitteri A. (2010). Maternal & Child Health Nursing. Care of the Childbearing & Childrearing Family. Lippincott
Williams & Wilkins, p. 562. 2
23 Viswanathan M, Hartmann K, Palmieri R, et al. The Use of Episiotomy in Obstetrical Care: A Systematic Review:
Summary. May 2005. In: AHRQ Evidence Report Summaries. Rockville (MD): Agency for Healthcare Research and Quality (US); 1998-2005. 112. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11967/ and WHO, Care in Normal Birth. A Practical Guide. 1996, p. 28
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damages to the baby’s head because the perineum is too much tight to permit a natural birth.24 As
clear, episiotomy is a practice which has to be used in some specific cases requiring medical intervention. Nevertheless, some experts believe than the practice of episiotomy helps the mum giving birth, accelerating the whole process and making it easier for the baby, too.25
It has been scientifically proved almost 30 years ago that it does not help women giving birth at all. On the contrary, when the cutting reaches the anus, it brings a lot of pain, including during later sexual relations, and urinary and faecal incontinence among other problems.26
And many later reports have confirmed that there are no benefits from episiotomy.27 On the contrary, “the routine use of this procedure is harmful inasmuch the same proportion of women who would have had lesser injury instead had a surgical incision.”28
Even the WHO recall that “the systematic use of episiotomy is not justified. And it also added that “the protection of the perineum through alternative methods should be always evaluated and adopted.”29
Even though there has been a decrease in the rate of episiotomy throughout the last century, today’s rate is still too much high according to the average ratio of 10% given by the WHO30. It is necessary to say, however, that the incidence of episiotomy performed is not the same throughout the world. The rate considerably varies according to the country. For example, the rate of episiotomies performed in the USA is 62.50% whilst in Europe it is less than half (30% throughout the continent and it drops as low as 9.70% in Sweden). In Taiwan the rate is 100%.31
As Marsden Wagner, the former Director of Women's and Children's Health for the WHO 32, declared referring to the situation in Spain “performing too many episiotomies has accurately been tagged as another form of genital mutilation on women […]. The rate of 89% in Spain is a scandal and a tragedy.” After his declaration, the rate of episiotomy in Spain dramatically reduced. Nevertheless,
24 WHO. (1996). Care in Normal Birth. A Practical Guide. Geneva, Switzerland. Retrieved from
http://www.who.int/maternal_child_adolescent/documents/who_frh_msm_9624/en/ p. 29
25 See for example data in Hong Jiang, Xu Qian, Carroli G. et al., Selective versus routine use of episiotomy for vaginal
birth. The Cochrane Database of Systematic Reviews, (2), 2017. CD000081. Advance online publication. http://doi.org/10.1002/14651858.CD000081.pub3
26 NHS. (2017). Episiotomy and perineal tears. Available at https://www.nhs.uk/conditions/
pregnancy-and-baby/episiotomy/?? Retrieved 15 January 2018
27 Gün İ., Doğan B., Özdamar Ö. (2016). Long- and short-term complications of episiotomy in Turkish Journal of
Obstetrics and Gynecology, 13(3). pp. 144–148.
28 Hartmann K., Viswanathan M., Palmieri R., et al. (4 May 2005). Gartlehner G, Thorp J, Lohr KN. Outcomes of Routine
Episiotomy. A Systematic Review. JAMA vol 293(17), p. 7.
29 WHO. (24 August 1985). Appropriate technology for birth. Lancet. Volume 326, Issue 8452, pp. 436–437 30 Ibid at 24, p. 29
31 Ibid p. 9
32 Marsden Wagner served as Director of Women's and Children's Health for the WHO for 15 years during which time
16
the new rate is considered still too high. More recent researches keep presenting further evidence against the frequent use of episiotomy33 and that episiotomy should be avoided if at all possible.34
Secondly, the Caesarean or C-section is probably the most criticised birth method both for the physical pain, later complications, long-term issues, and for the measures to adopt after the surgery. Some of the countries with less perinatal mortality show less than 10% of C-sections.35 When C-section rates in a country are around 10%, there is a significant decrease in maternal and new-born deaths. But when the rate is over 10%, there is no evidence that death rates improve.36 So, it is not justifiable to have a higher rate than 10-15% as recommended by the WHO in its Guidelines.37 In addition to that, it is not proved that after a C-section, a woman must go through a C-section again. It is possible and recommended to give a vaginal birth even though in 90% of the cases, women will give subsequent births by C-section as well.38 According to the most recent data, the average rate of C-section in the world is 18.6%. It ranges from 6.0% to 27.2% according to the regions. The lowest rates are found in Africa (7.3%) whilst the highest are found in Latin American and the Caribbean (40.5%). South America is the sub region with the highest average rates in the world (42.9%). Brazil for example has a rate of C-section of 55.6%.39
Thirdly, the uterine fundal pressure, better known as Kristeller manoeuvre from the name of Samuel Kristeller, a Berlin obstetrician who in 1867 created such procedure. 40
The manoeuvre consists in pushing down on the top of the uterus in order to accelerate the expulsion. The same Kristeller has described it as “an aid in weak uterine contractions” at the time of expulsion (second stage of delivery).41Apart from being a painful manoeuvre for the mum, it can be dangerous for the uterus, the perineum and the same foetus which can suffer from severe damages because of the unnatural pushing.42 According to a research published in the Central European Journal of
33 See foe example Klein, M, Gauthier, R, Jorgensen, S et al. Does episiotomy prevent perineal trauma and pelvic floor
relaxation? 1992
34 Berghella V. (2012). Obstetric Evidence Based Guidelines. NY: Taylor & Francis Group, p. 79
35 WHO. (2015). Statement on caesarean section rates. Geneva, Switzerland. Retrieved from
http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/, p. 3
36 Ibid. 37 Ibid.
38 The New York Times, August 28, 2017. Last accessed 15 January 2018. Retrieved at
https://opinionator.blogs.nytimes.com/2016/01/19/arsdarian-cutting-the-number-of-c-section-births/
39 Betrán P., Ye, Moller at al. (February 5, 2016). The Increasing Trend in Caesarean Section Rates: Global, Regional and
National Estimates: 1990-2014. Retrieved at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0148343
40 Waszyński E. (2008). Kristeller's procedure. Expressio fetus, its genesis and contemporary application in Ginekol Pol.
Apr;79 (4), pp.297-300
41 Dubravko Habek, Mirna Vuković Bobić, Zlatko Hrgović. (2008). Possible feto-maternal clinical risk of the Kristeller’s
expression in Central European Journal of Medicine, vol. 3(2), pp. 183-186
42 Miles Chile. (December 2016). Primer Informe Salud Sexual Salud Reproductiva y Derechos Humanos en Chile. Estado
de la situación 2016, pp. 233-234. Retrieved from http://www.mileschile.cl/documentos/Informe_DDSSRR_2016_Miles.pdf pp. 233-234
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Medicine43 “in line with the principles of modern obstetrics, Kristeller manoeuvre should be reserved
for the specific rare cases in case of large child or other critical medical conditions therefore its use can be avoided in the majority of cases.”
Source of argument is also the use of synthetic oxytocin. Oxytocin, also known as the love hormone, causes uterine contractions and then it is used to induce labour. This intervention is considered by the WHO as a mayor intervention due to the side effects and dangers its use involves. For these reasons, it should be used only under specific indication. Some of the risks it involves are: uterine rupture, a higher rate of C-section and use of forceps, more pain for the woman and so a mayor need for pain relief, and severe foetal distress.44
Another focal point concerns the position to adopt during the delivery. The WHO does not recommend placing the pregnant woman on a lithotomy position (dorsal position) during the dilation of cervix and during the delivery.45 The lithotomy position is the general position gynaecologists and obstetricians use during their medical examinations: the woman lies on her back with her thighs open and the legs flexed and supported in raised stirrups. Even though this position provides excellent surgical access to the perineum, it is preferable to walk during the dilatation and every woman should be free to decide the position that best fits for the delivering.46
Other important procedures which are often performed to induce labour are the amniotomy or the artificial rupture of membranes (AROM), foetal monitorization, enemas and pubic shaving.
The artificial rupture of membranes or amniotomy consists in deliberately break the amniotic sac in order to release the amniotic fluid and accelerate the birth.47 In normal labour there should not be a necessity for interfering with the artificial rupture of membranes.48
For what concern foetal monitorization, as outlined by a research made by FIGO (International Federation of Gynaecology and Obstetrics)49 there is no evidence that the routine foetal monitorization has a positive effect and it should be carried out only under specific circumstances. Finally, an enema is the injection of a liquid or a gas into the rectum to empty their bowels. It is believed that reduces the possibility of an infection and, at the same time, makes space for the baby
43 Ibid. at 41
44 Ibid at 42 45 Ibid. 46 Ibid.
47 O'Connell N. G., Walker B. L. (2016). Amniotomy Technique. Retrieved from
https://emedicine.medscape.com/article/1997932-technique
48 Ibid at 42
49Ayres-de-Campos D., Spong C.Y., Chandraharan E. FIGO consensus guidelines on intrapartum foetal monitoring. Int
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at the moment of labour. On the contrary, enemas have no salutary effects and that is the reason why it is convenient to cut the rate of enemas performed.50 Enemas cause increased pain during labour and even could potentially increase the risk of infections and have no significant benefits on infection rates such as perineal wound infection or other neonatal infections and women’s satisfaction.51
According to the WHO, enemas have no result on preventing infections of perinatal wound and other neonatal infections therefore the habit of enemas, as well as other practices must be limited.52 Pubic shaving has no resulted in preventing infections, either, on the contrary, it increases the risk of infection as micro abrasions resulting from the shaving can generate infections.53
2.2 Mental impact of obstetric violence
Apart from the physical procedures which can be involved in obstetric violence, the psychological sphere plays an important role in women’s health during and after labour. Mistreatments as listed above can contribute to many mental disorders with negative effects on the health of both the mum and the new-born. In particular, it can cause post-traumatic stress disorder 54 and postpartum depression.
As shown in a Brazilian study published in 2017 55 aimed to investigate the association between institutional violence in obstetrics and postpartum depression, there is an actual direct link between “mistreatment and adverse maternal, perinatal and infant outcomes in the same birth. In particular, mistreatment may contribute to maternal postpartum depression and post-traumatic stress disorder, particularly in cases of extreme abuse. Mistreatment may also be associated with decreased rates of breastfeeding initiation.”
The study continues identifying the correlation between the quality of the obstetric care received during puerperal period and some psychiatric disorders that can arise, namely postpartum depression. Elements that can affect such disorders are, as listed in the article, ''the feeling of abandonment during delivery, inadequate pain management, frustration for having delivered via caesarean section when natural childbirth was possible, and the pregnant woman’s perception of the team who provided the care''. Women who experienced mistreatment during maternal care, either physical or verbal, are
50 Ibid at 42
51 Reveiz L., Gaitán H. G., Cuervo L.G. (2013). Enemas during labour, p. 2. Available at
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000330.pub4/epdf
52 Ibid at 42
53 WHO. (1996). Care in Normal Birth. A Practical Guide. Geneva, Switzerland. Retrieved from
http://www.who.int/maternal_child_adolescent/documents/who_frh_msm_9624/en/ p. 8
54 Ibone Olga Fernandéz. (2014). Estrés postraumático secundario en profesionales de la atención al parto. Aproximación
al concepto de violencia obstétrica in C. Med. Psicosom, Nº 111, 2014, pp. 79-83
55 Junqueira de Souza K., Rattner D., Bauermann Gubert M. (2017). Institutional violence and quality of service in
19
seven times more at risk of developing postpartum depression compared to women who did not suffered any mistreatment.56
Another important outcome in the psychological field is that obstetric violence can influence women’s decision not to choose hospital facilities for their subsequent pregnancies and swift to a home birth. This increases the risks associated to the performance of labours and deliveries without the assistance of a trained and skilled birth attendant. A birth without assistance can have either positive and negative outcomes depending on many factors but even in presence of a normal pregnancy, many factors can lead to an emergency during the delivery.
2.3 Women in subordination in the medical field
For many years, the control over women’s bodies has been a key point to maintain women in subordinate position.57 The major part of the society and, within it, the social relations are erected in
a patriarchal way. The term “patriarchy” used to refer to the nuclear family organisation which presented a patriarch, a man, as head of the whole family and under his guide, the wife, children and various relatives more. Nowadays the acceptation of patriarchy is used “to refer to male domination, to the power relationships by which men dominate women, and to characterise a system whereby women are kept subordinate in a number of ways.”58 Roles of patriarchy can be seen in both public
and private sector and health facilities are not exempt from them.
In the field of medicine, there has been for ages a huge disproportion between female obstetrics and gynaecologist compared to the total number of male professionals performing the same role. Even though the proportion of women entering medicine had more than doubled since 1980, it is not possible to overlook the difficulties and the delay women could enter medical schools and educated themselves to medical careers until some years ago. It was only at the end of the XIX century59 that the first women from certain countries, managed to enter medical schools and ten years ago, apart from exceptions, “men continued to dominate the medical profession, while other health service providers remained predominantly female”.60 Moreover, “women tended to be concentrated in the
56 Ibid.
57 Mikkola, Mari. (2017). Feminist Perspectives on Sex and Gender, The Stanford Encyclopaedia of Philosophy, Winter 2017 Edition. Edward N. Zalta (ed.). Available at https://plato.stanford.edu/archives/win2017/entries/feminism-gender/ 2008
58 Sultana A. (2012). Patriarchy and Women’s Subordination: A Theoretical Analysis. Arts Faculty Journal, [S.l.] p. 2 59 Dr. Elizabeth Blackwell is internationally recognised as the first women who graduated from a medical school in the
USA in 1849
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lower-status health occupations, and to be a minority among more highly trained professionals.”61
Just in recent years, there has been a trend reversal.
Another point to highlight is the fact that childbirth and motherhood have been seen for centuries as a duty (even not when THE only duty) for a woman.62
The WHO estimates that more than 135 million pregnancies occur each year63, the majority of which being the first child for a woman. Even when a woman is at her second or third pregnancy, the same pregnancy, labour and postpartum period can widely differ from the previous ones for many different reasons such as the age, complicacies and a general broad variety of different factors that can influence the whole pregnancy. As the labour has been so medicalised and due to the fear of complications during birth which is reasonably high, women prefer to rely heavily on a professional as medical staff have been trained to quickly evaluate the problem and have a prompt and effective response for it.
According to the report issued in Mexico in 2013 by GIRE (Grupo de Información sobre la
Reprodución Elegida - Information Group on Reproductive Choice), Regina Tamés, a Mexican
lawyer expert in the field of human rights, reproductive rights and advocacy defines the obstetric violence as “the result of the institutionalization of childbirth when it becomes customary to deliver babies in health centres rather than at home. With this paradigm shift, childbirth cease to be something natural and became a medical practice.”
2.4 Today’s characteristics
Studies on the issue identified three patterns of behaviour during childbirth which are: “health care personnel using their positions of power and control to intimidate women; women unaccustomed to defending their rights easily accepting the role they are forced into as hospital patients, thereby reflecting and replicating the oppressive situation in which they find themselves; public health institutions, through their structure and mechanisms, discouraging women from pursuing formal complaints.”64
A patriarchal relationship constitutes the perfect foundation for a possible violation of human rights and can take different forms. For example, the fixed gap role between health care personnel and patient makes that since the very first entry of a pregnant woman to the maternity ward, she has to
61 Ibid.
62 Bellón Sanchéz Silvia. (2014). Obstetric Violence. Medicalization, authority and sexism within Spanish obstetric
assistance (Master’s degree thesis, Utrecht University, Netherlands and Universidad de Granada, Spain), p. 26
63 WHO. (November 2015). 10 Facts on Maternal Health. Retrieved from
http://www.who.int/features/factfiles/maternal_health/en/l
64 Castro R., Erviti J. (2003), Violations of Reproductive Rights During Hospital Births in México Health and Human
21
withstand to what the doctor says or being threatened of severe consequences for her and the baby. “Cooperative” women are better considered among the women who enter the maternity ward but at the same time, they are the easier one to blame in case of complications or poor outcome. If a woman is not “cooperative”, doctors can choose from a wide range of tactics to convince her about the necessity for a certain procedure, sometimes using coercion or threat to obtain consent, some others invalidating information and percentages on the procedures.65
Others practices that degrade the role of the women during their pregnancy is when the personnel are dismissive about any information or knowledge a woman might have about her condition as well as when they provide little if any information about it. An even more pervasive act is the invalidation of women’s suffering which has a direct link on invalidating also women’s response and reactions to pain. In correlation with the pain as tribute, many health professionals make inappropriate sexual allusion to the pleasure the woman had during conception and try to put it in correlation of the pain they go through during labour.66
Obstetric slang used among doctors in the maternity ward can be disrespectful, too. The most famous example is the so called “husband's stitch”.67 The practice consists in suturing the vaginal opening
after a delivery with one or more extra stitches to make the canal tighter. Theoretically, in doing so, husbands will experience more pleasure during future sexual intercourses. Instead, women will experience just more pain and general discomfort.
For different reasons, women usually accept the fact that their rights are being violated, above all for their baby’s health. In some cases, they actually justified certain kinds of abuse they received from physicians as “logical”. Nevertheless, in doing so, women unknowingly contribute to the mistreatment.68
3. Reproductive rights. An historic overview
As obstetric violence undermines women’s reproductive rights and health, it is necessary to summarise the most important milestones in the path of reproductive rights under which obstetric violence can find a frame.
Many articles in international tools safeguard the right to health, for example the 1966 International Covenant on Economic, Social and Cultural Rights which at its Article 12(1) states that “[t]he States Parties [...] recognize the right of everyone to the enjoyment of the highest attainable standard of
65 Ibid. p. 100
66 Ibid.
67 Fernández Guillén F. (2015). ¿Qué es la violencia obstétrica? Algunos aspectos sociales, éticos y jurídicos. Dilemata,
year 7 No. 18, pp. 113-128, p. 118
22
physical and mental health.69” Nevertheless, the history of reproductive rights started some years and
documents later.
In 1948, the Universal Declaration of Human Rights, states at its Article 16(1) that all women and men have the right to found a family without any limitation,70 right later recollected in Article 23 of the International Covenant on Civil and Political Rights.71
The first time we found a mention of what would have been part of the so-called reproductive rights, was in 1968 in the Resolution XVIII on the Human Rights Aspects of Family Planning72 adopted at the International Conference on Human Rights in Tehran. The Proclamation states that “[...] parents have a basic human right to determine freely and responsibly the number and the spacing of their children and a right to adequate education and information in this respect”73, right reiterated at the
first of the three conferences on population which took place in Bucharest74, on the paragraph 14 in the Principles and Objectives of the World Population Plan of Action. Only later in 1969, there will be added that “parents have the exclusive right to determine freely and responsibly the number and spacing of their children”75 underlining the exclusivity of parents to decide about the number of
children they wanted and the spacing they preferred.
Considered as an international bill of rights for women, the 1979 the Convention on the Elimination of All Forms of Discrimination against Women76 at its Article 16(e) reiterates the need of the State to ensure these right on a basis of equality of men and women.
Ten years after the first World Conference on Population in Bucharest, Mexico City hosted the second global conference on population. The 25th recommendation for implementation of the World Population Plan of Action urges governments to make universally available “information, education and the means to assist couples and individuals to achieve their desired number of children.”77 In this
69 UN General Assembly, International Covenant on Economic, Social and Cultural Rights. 16 December 1966. Available
at http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx
70 UN General Assembly, The Universal Declaration of Human Rights. Paris, 10 December 1948. Available at
http://www.un.org/en/universal-declaration-human-rights/
71 UN General Assembly, International Covenant on Civil and Political Rights. 16 December 1966. Available at
http://www.ohchr.org/EN/ProfessionalInterest/Pages/CCPR.aspx
72 UN General Assembly, Final Act of the International Conference on Human Rights, Resolution XVIII. Teheran, Iran
20 December 1968. Available at http http://legal.un.org/avl/pdf/ha/fatchr/Final_Act_of_TehranConf.pdf
73 UN General Assembly, Resolution XVIII: Human Rights Aspects of Family Planning, Final Act of the International
Conference on Human Rights. Tehran, Republic of Iran, 22 April to 13 May 1968. Available at http://legal.un.org/avl/pdf/ha/fatchr/Final_Act_of_TehranConf.pdf
74 World Conference on Population, World Population Plan of Action. Bucharest, Romania. 19 August 1974 - 30 August
1974. Available at http://www.unfpa.org/sites/default/files/event-pdf/World%20Population%20Plan%20of%20Action_1.pdf
75 UN General Assembly, Declaration on Social Progress and Development, Article 4. 11 December 1969. Available at
http://www.ohchr.org/Documents/ProfessionalInterest/progress.pdf
76 UN General Assembly, the Convention on the Elimination of All Forms of Discrimination against Women, 18
December 1979. Available at http://www.un.org/womenwatch/daw/cedaw/text/econvention.htm#article12
77 International Conference on Population. Recommendations for the Further Implementation of the World Population
Plan of Action. Mexico City, Mexico, 06 August 1984 - 14 August 1984. Available at http://www.un.org/popin/icpd/conference/bkg/mexrecs.html
23
regard, the recommendation stated that all type of information, the education and the means about family planning provided by governments should rely on “all medically approved and appropriate methods [...], including natural family planning, to ensure a voluntary and free choice in accordance with changing individual and cultural values.” A great emphasis is put on the freedom of women and men to choose the right family plan according to their customs and traditions. The article ended underling the particular attention with should be used to reach the most vulnerable and difficult segments of the population”78.
Another 10 years passed and in 1994, the International Conference on Population and Development (ICDP) took place in Cairo.79 The Conference adopted the Programme of Action which introduced the concepts of sexual and reproductive health and reproductive rights. The definition of reproductive rights was finally agreed for the first time globally. It defined reproductive health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.” Reproductive health is than seen in a complex way as the article continues: “reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition there are the rights of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.”80
In the following paragraph, it recognised that reproductive rights “[...] embrace certain human rights that are already recognized in national laws, international human rights documents and other relevant United Nations consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes the right of all to make decisions concerning reproduction free of discrimination, coercion and violence as expressed in human rights documents. In the exercise of this right, they should consider the needs of their living and future children and their responsibilities towards the community.”81
78 Ibid.
79 International Conference on Population and Development. Programme of Action. Cairo, Egypt, 5-13 September 1994.
Available at https://www.unfpa.org/sites/default/files/event-pdf/PoA_en.pdf
80 Ibid. para 7.2 81 Ibid at 79, para 7.3
24
The definition continues with the objects to pursue and states stating the importance of the state as “the promotion of the responsible exercise of these rights for all people should be the fundamental basis for government- and community-supported policies and programmes in the area of reproductive health, including family planning [...].”82 It then illustrates the actions that any state should take: make reproductive health accessible through the primary health care system, include services and other information and the discouragement of harmful practices in their policies,83 develop innovating programs,84 promote a better reproductive health through a decentralization of health programmes and through the cooperation with different organisations and health care providers85 among other initiatives.
So, even though the concept of reproduction health had appeared in research literature and in the vocabulary of health policy over the years, the unanimous definition of the concept finally appeared at the International Conference on Population and Development in Cairo in 1994.
One year later, in Beijing, the fourth World Conference on Women Action for Equality, Development and Peace adopted the Platform for Action (PfA),86 an agenda for women's empowerment. Among its strategic objectives, it committed states parties to undertake gender-sensitive initiatives that address sexual and reproductive health issues. The Programme of Action born from the conference defines reproductive health as in ICPD Programme of Action87 and it recognised that “[...] human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. Equal relationships between women and men in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behaviour and its consequences.”88
At the following paragraph, it further denounces that “[...] women are subject to particular health risks due to inadequate responsiveness and lack of services to meet health needs related to sexuality and reproduction.”89 This has a repercussion on women’s health as complications related to
pregnancy and childbirth and unsafe abortion are on the leading causes or mortality of women.90 It is
82 Ibid.
83 Ibid. para 7.6 and 7.7 84 Ibid. para 7.8 85 Ibid. para 7.9
86 Fourth World Conference on Women, Beijing Declaration and Platform for Action. Beijing, 4 to 15 September 1995.
Available at http://www.un.org/womenwatch/daw/beijing/pdf/BDPfA%20E.pdf
87 Ibid. para 94 88 Ibid. para 96
89 Fourth World Conference on Women, Beijing Declaration and Platform for Action, para 97. Beijing, 4 to 15 September
1995
25
recognised that most of these deaths, health problems and injuries are preventable through improved access to adequate health-care services.91
Linked to this definition, the WHO defines reproductive health care as the “constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems.”92 It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.
3.1 Reproductive Rights (not) in the MDGs but in the SDGs Agenda
At the turn of the century, the leader of 189 states gathered and signed the historic Millennium Declaration. Through eight goals, states committed to half extreme poverty and hunger, to promote gender equality and to reduce child mortality, by the target date of 2015.
In the original document, the Secretary General’s report from which the declaration and the goals were drawn, reproductive health was not encompasses in any of the MDGs. When it is mentioned, it was always indirectly.
One year later, in August 2001, the eight MDGs drawn from the declaration, alongside with indicators and targets were published. The goals and indicators again had no explicit commitment to women’s reproductive health since “if it wasn’t in the declaration it couldn’t be in the goals”93 and alongside
with a strong G-77’s opposition in changing the labelling of “maternal health” to “reproductive health” in one of the goals during the works.
The MDGs have then reduced the broad sexual and reproductive health and rights agenda to the only domain of maternal health.94
Nevertheless, the UN, considered that “of the eight Goals, three - improve maternal health, reduce child mortality and combat HIV/AIDS, malaria and other diseases - are directly related to reproductive and sexual health, while four others - eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, and ensure environmental sustainability - have a close relationship with health, including reproductive health.” Despite the correlations, pressure was made until 2007, when the MDG monitoring framework was revised to include four new targets among which, a new target on Goal 5 - universal access to
91 Ibid
92 WHO. (n.d.). Reproductive Health. Available at http://www.wpro.who.int/topics/reproductive_health/en/
93 Michael Doyle in an interview released on 10 November 2004. He led the working committee for the MDGs during
several months of discussions and negotiations
94 Yamin AE, Falb KL. (2012). Counting what we know: knowing what to count: sexual and reproductive rights, maternal
